Vertical Transmission of Coxsackievirus A6 with Severe Congenital Pneumonia/Sepsis

We report a case of vertical transmission of Coxsackievirus (CV)-A6 with severe congenital pneumonia/sepsis. A male infant presented with severe respiratory symptoms at birth and was treated with full cardiopulmonary support, including inhaled nitric oxide. Three days before delivery, his older brother was diagnosed with hand, foot, and mouth disease (HFMD). His mother developed transient fever 1 day before delivery and presented a blister on her thumb 2 days after delivery. A multiplex polymerase chain reaction test on day 2 was positive for human rhinovirus/enterovirus. CV-A6 was later detected in the serum, tracheal aspirate, and stool of the patient sampled on day 6, and in the maternal serum sampled on the day of delivery. He was diagnosed with congenital CV-A6 pneumonia/sepsis caused by vertical transmission, based on VP1 consensus sequences used for typing of the virus that demonstrated a 100% match between the mother and infant. Further, the strain was closely related to the lethal CV-A6-Changchun strains in the phylogenetic analysis of the P2 region, which contributes to the pathogenicity. In conclusion, congenital CV-A6 infection should be considered if a woman exhibits HFMD symptoms during the perinatal period. Detailed virologic examination is useful for understanding its pathogenesis.

Pediatric Infections by Human mastadenovirus C Types 2, 89, and a Recombinant Type Detected in Japan between 2011 and 2018

Between 2011 and 2018, 518 respiratory adenovirus infections were diagnosed in a pediatric clinic in Shizuoka, Japan. Detection and typing were performed by partial sequencing of both hexon- and fiber-coding regions which identified: adenovirus type 1 (Ad-1, n = 85), Ad-2 (n = 160), Ad-3 (n = 193), Ad-4 (n = 18), Ad-5 (n = 27), Ad-11 (n = 2), Ad-54 (n = 3), and Ad-56 (n = 1). Considering previous reports of the circulation of an endemic recombinant Ad-2, e.g., Ad-89, 100 samples typed as Ad-2 were randomly selected for further molecular typing by sequencing the penton base-coding region. Despite the high nucleotide sequence conservation in the penton base- coding region, 27 samples showed 98% identity to Ad-2. Furthermore, 14 samples showed 97.7% identity to Ad-2 and 99.8% identity to Ad-89, while the remaining 13 samples showed an average 98% pairwise identity to other Ad-C types and clustered with Ad-5. The samples typed as Ad-89 (n = 14) and as a recombinant Ad type (P5H2F2) (n = 13) represented 27% of cases originally diagnosed as Ad-2, and were detected sporadically. Therefore, two previously uncharacterized types in Japan, Ad-89 and a recombinant Ad-C, were shown to circulate in children. This study creates a precedent to evaluate the epidemiology and divergence among Ad-C types by comprehensively considering the type classification of adenoviruses.

Three Severe Cases of Viral Infections with Post-Kidney Transplantation Successfully Confirmed by Polymerase Chain Reaction and Flow Cytometry

Viral infections in patients with post-kidney transplantation are often difficult to diagnose as well as treat. We herein report three cases with severe viral infections after kidney transplantation. All their causative pathogens could be detected promptly by polymerase chain reaction and flow cytometry during the early stages of infection. These examinations would also be of great use to monitor therapeutic responses and disease activity. It is indeed true that no specific treatment is available for most of the viral infections, but we should be aware that some infections, such as Epstein-Barr virus infection, can be treatable with prompt and specific treatment, such as rituximab.

Changes in Bradykinin and Prostaglandins Plasma Levels during Dextran-sulfate Low-density-lipoprotein Apheresis

The negative charges of dextran-sulfate (DS) used for low-density-lipoprotein (LDL) apheresis initiate the intrinsic coagulation pathway in which plasma kallikrein acts on the high-molecular-weight kininogen to produce large amounts of bradykinin. This study was undertaken to assess whether bradykinin generated during DS LDL apheresis has any physiologic effects in vivo. The plasma levels of bradykinin, prostaglandins and cyclic guanosine monophosphate (cGMP) were compared, when either of two anticoagulants, heparin or nafamostat mesilate (NM), was used during DS LDL apheresis. Although anticoagulative action by NM depends on the inhibition of thrombin activity, this substance also inhibits the activity of plasma kallikrein. During apheresis using heparin, the plasma levels of prostaglandin E2 (PGE2) increased significantly (5.6 ± 1.2 (mean ± SE, n=4) pg/ml before apheresis and 33.4 ± 13.2 after apheresis, p < 0.05) in association with an increase in bradykinin levels (17.9 ± 2.6 pg/ml before apheresis and 470 ± 135 after apheresis, p < 0.01). Interestingly, these changes were suppressed during apheresis using NM. There were no appreciable changes in cGMP during DS LDL apheresis with either of the anticoagulants. This finding suggests that bradykinin generated during apheresis has some pathophysiological effects via activation of the prostaglandin system. Our results support the view that in patients taking angiotensin-convertingenzyme inhibitors, the anaphylactoid reaction occurring during apheresis may be caused by an excessive rise in the bradykinin levels.

Characterization of genome sequences and clinical features of coxsackievirus A6 strains collected in Hyogo, Japan in 1999-2013

Coxsackievirus A6 (CV-A6) is an enterovirus, which is known to cause herpangina. However, since 2009 it has frequently been isolated from children with hand, foot, and mouth disease (HFMD). In Japan, CV-A6 has been linked to HFMD outbreaks in 2011 and 2013. In this study, the full-length genome sequencing of CV-A6 strains were analyzed to identify the association with clinical manifestations. Five thousand six hundred and twelve children with suspected enterovirus infection (0-17 years old) between 1999 and 2013 in Hyogo Prefecture, Japan, were enrolled. Enterovirus infection was confirmed with reverse transcriptase-PCR in 753 children (791 samples), 127 of whom (133 samples) were positive for CV-A6 based on the direct sequencing of the VP4 region. The complete genomes of CV-A6 from 22 positive patients with different clinical manifestations were investigated. A phylogenetic analysis divided these 22 strains into two clusters based on the VP1 region; cluster I contained strains collected in 1999-2009 and mostly related to herpangina, and cluster II contained strains collected in 2011-2013 and related to HFMD outbreak. Based on the full-length polyprotein analysis, the amino acid differences between the strains in cluster I and II were 97.7 ± 0.28%. Amino acid differences were detected in 17 positions within the polyprotein. Strains collected in 1999-2009 and those in 2011-2013 were separately clustered by phylogenetic analysis based on 5'UTR and 3Dpol region, as well as VP1 region. In conclusion, HFMD outbreaks by CV-A6 were recently frequent in Japan and the accumulation of genomic change might be associated with the clinical course.

A pediatric patient with interstitial pneumonia due to enterovirus D68

Enterovirus D68 (EV-D68) infection is associated with upper and lower respiratory tract symptoms such as fever, cough, and wheezing. Pediatric patients with EV-D68 infection easily develop more severe respiratory complications compared to patients infected with other species of enterovirus, and consequently, have a higher rate of hospitalization and admission to intensive care units. Therefore, the clinical picture of respiratory complications associated with EV-D68 infection needs to be elucidated. Here, we report a 4-year-old girl of EV-D68 infection that required artificial respiration management within 24 h from the onset of cold symptoms. The patient was diagnosed with interstitial pneumonia on the basis of chest imaging findings with patchy, funicular and frosted glassy shadows, increased blood markers of surfactant protein-A, surfactant protein-D and sialylated carbohydrate antigen KL-6, and increased neutrophils and lymphocytes in the bronchoalveolar lavage. Steroids showed a remarkable effect in her treatment. Further investigations are needed to confirm the efficacy of steroids for interstitial pneumonia due to EV-D68 infection. As rapid deterioration of respiratory status is observed in EV-D68 infection, the possibility of interstitial pneumonia may be considered.

Low total IgM values and high cytomegalovirus loads in the blood of newborns with symptomatic congenital cytomegalovirus infection

AIMS

Neurological outcomes differ considerably between symptomatic and asymptomatic infants with congenital cytomegalovirus (CMV) infection. Our objective was to characterize laboratory markers in symptomatic newborns in comparison with asymptomatic newborns with congenital CMV infection.

METHODS

Ten newborns with symptomatic and 13 newborns with asymptomatic congenital CMV infection were included in this 3-year prospective cohort study. Total immunoglobulin M (IgM), CMV-IgM, CMV antigenemia, and CMV-DNA in blood and urine were measured and their positive rates and quantitative values compared between the symptomatic and asymptomatic groups.

RESULTS

Fifty percent of newborns in the symptomatic group were positive based on total IgM; this was significantly lower than in the asymptomatic group (100%). Quantitative total IgM values were significantly lower, and there were significantly more copies of CMV-DNA in the blood of symptomatic newborns than in asymptomatic newborns (median values for total IgM: 14 vs. 43 mg/dL and blood CMV-DNA: 3.2×102 vs. 3.5×101 copies/106 white blood cells). CMV-IgM, CMV antigenemia, and urine CMV-DNA did not differ significantly between groups.

CONCLUSION

Low total IgM values and high blood CMV loads were associated with the presence of symptoms in newborns with congenital CMV infection.

Expression of plasma membrane Ca2+-ATPase on hepatic sinusoidal endothelial fenestrae: modification of the one-step method

The intracytoplasmic free calcium ion (Ca2+) concentration is maintained at a low level in mammalian tissues by extruding Ca2+ against a high extracellular Ca2+ concentration, mainly through the activity of the plasma membrane Ca2+-ATPase pump. The objective of the present study was to localize the plasma membrane Ca2+-ATPase activity on hepatic sinusoidal endothelial cells (SECs) by electron microscopic cytochemistry. The ultrastructural localization of Ca2+-ATPase activity on ultrathin sections of liver tissue and cultured SEC monolayer was examined by the electron microscopic cytochemical method of Ando (method A: original method) and by our modified method (method B: shortened fixation method). By method A, scanty cytochemical reaction products of Ca2+-ATPase were found in the SECs. By method B, Ca2+-ATPase activity was clearly localized on the outer surface of the plasma membrane of sinusoidal endothelial fenestrae (SEF). Our modification of Ando's method by shortening the incubation time of liver tissue or isolated SEC sections in the substrate allowed clear demonstration of Ca2+-ATPase activity on the SEF membrane. Use of tangential sections of primary cultures of SEC provided excellent localization results. The cytochemically reactive Ca2+-ATPase expressed on the SEF plasma membrane may be involved in regulation of the intracytoplasmic Ca2+ concentration.

Endothelial nitric oxide synthase and caveolin-1 are co-localized in sinusoidal endothelial fenestrae

BACKGROUND/AIMS

Nitric oxide is synthesized in diverse mammalian tissues by a family of calmodulin-dependent nitric oxide synthases (NOS). Caveolin, the principal structural protein in caveolae, interacts with endothelial NOS leading to enzyme inhibition in a reversible process modulated by Ca++-calmodulin. The aim of the present study was to clarify the ultrastructural localization of eNOS and caveolin-1 in hepatic sinusoidal endothelium by an electron immunogold method.

METHODS

Male Wistar rats were used. Liver tissues and hepatic sinusoidal endothelial cells isolated from rat livers by collagenase infusion were studied. For immunohistochemistry, liver specimens were reacted with anti-eNOS or anti-caveolin-1 antibody. The ultrastructural localization of eNOS or caveolin-1 was identified by electron microscopy using an immunogold post-embedding method.

RESULTS

Immunohistochemical studies using liver tissues localized endothelial NOS in hepatic sinusoidal lining cells, portal veins and hepatic arteries; and caveolin-1 in sinusoidal lining cells, bile canaliculi, portal vein and hepatic arteries. Immunogold particles indicating the presence of eNOS and caveolin-1 were demonstrated on the plasma membrane of sinusoidal endothelial fenestrae in liver tissue and also in isolated sinusoidal endothelial cells.

CONCLUSION

Endothelial NOS and caveolin are co-localized on sinusoidal endothelial fenestrae, suggesting that interaction of the two may modulate cellular regulation of NO synthesis.

Bile canalicular contraction and dilatation in primary culture of rat hepatocytes--possible involvement of two different types of plasma membrane Ca(2+)-Mg(2+)-ATPase and Ca(2+)-pump-ATPase

Increasing evidence has indicated that bile canalicular contraction is mediated by the nonmuscular Ca(2+)-calmodulin-actomyosin system, and the contraction facilitates canalicular bile flow. The aim of the present study was to examine, by electron cytochemistry, how the expression of two types of plasma membrane Ca(2+)-ATPase, i.e., Ca(2+)-Mg(2+)-ATPase and Ca(2+)-pump-ATPase, is related to the dynamic changes of bile canalicular contraction. Hepatocytes isolated from male Wistar rat liver by collagenase perfusion were cultured to form a primary monolayer. The canalicular dynamics in the couplets and triplets were analyzed by time-lapse cinematography. The Ca(2+)-Mg(2+)-ATPase activity was identified by the electron cytochemical method of Ando. Ultrastructural localization of Ca(2+)-pump-ATPase was examined by immunogold electron microscopy. We found that cytochemical reaction products showing the presence of Ca(2+)-Mg(2+)-ATPase activity were localized on the luminal side of the bile canalicular membranes. Immunogold particles, indicating the presence of Ca(2+)-pump-ATPase, were located mainly on the cytoplasmic side of the bile canalicular membranes. The expression of both Ca(2+)-ATPases on the canalicular membranes was enhanced during the contracting stage of bile canaliculi, whereas their expression was diminished in the dilating stage. We conclude that two different types of bile canalicular Ca(2+)-ATPase may be involved in the regulation of canalicular contractility to control the extrusion of intracytoplasmic free calcium ions into the canalicular lumen.

Enhanced expression of endothelin receptor subtypes in cirrhotic rat liver

BACKGROUND/AIMS

A number of vasoactive substances have been implicated as potential mediators of intrahepatic portal hypertension. Endothelin (ET)-1 has been suggested to be involved in the regulation of hepatic microcirculation and development of portal hypertension. The aim of this study was to clarify the localization of two subtypes of ET receptors, ET A (ETAR) and B receptors (ETBR), in normal rat liver, and how the receptor expressions are altered in CCl4-induced cirrhotic rat liver.

METHODS

Liver specimens were examined immunohistochemically after reacting with anti-ETAR and anti-ETBR rabbit polyclonal antibodies. Immunogold staining was also performed using the same antibodies, and examined under light and electron microscopy.

RESULTS

In normal rat liver, immunohistochemistry revealed expression of ETAR and ETBR on the hepatic sinusoidal lining cells. By immunogold electron microscopy, electron-dense gold particles indicating the presence of ETARs were localized mainly on hepatic stellate cells (HSCs) and to a lesser extent on sinusoidal endothelial cells (SECs), while ETBRs were expressed equally intensely on HSCs and SECs. In cirrhotic animals, both ETAR and ETBR increased significantly on HSCs, while there were no significant increases in either receptor on SECs.

CONCLUSIONS

In the normal state, HSCs possess both ETARs and ETBRs, while SECs mainly possess ETBRs. In cirrhosis, endothelins may exert more intense effects on HSCs via the enhanced ETARs and ETBRs, causing an increase in hepatic sinusoidal microvascular tone.

Hepatic sinusoidal endothelial fenestrae express plasma membrane Ca++pump and Ca++Mg++-ATPase

BACKGROUND/AIM

In general, intracytoplasmic free calcium ions (Ca++) are maintained at a very low concentration in mammalian tissue by extruding Ca++ against a high concentration of extracellular Ca++, mainly through the activity of the plasma membrane Ca++pump-ATPase. The aim of the present study was to demonstrate by electron cytochemical and immunogold methods the ultrastructural localization of two different types of plasma membrane Ca++-ATPase, i.e. Ca++Mg++-ATPase and Ca++pump-ATPase in the hepatic sinusoidal endothelium.

METHODS

Liver tissues and the isolated hepatic sinusoidal endothelial cell (SEC)s were subjected to the following procedures. The ultrastructural localizations of Ca++Mg++-ATPase were examined by an electron cytochemical method. The ultrastructural localization of Ca++pump-ATPase was identified by an electron immunogold method.

RESULTS

The cytochemical reaction of Ca++Mg++-ATPase was found to be localized on the outer sites of the plasma membrane of sinusoidal endothelial fenestrae (SEF). The immunogold particles indicating the presence of Ca++pump-ATPase were identified on the inner sites (cytoplasmic) of the invaginated plasma membrane of SEF CONCLUSIONS: Both Ca++Mg++-ATPase and Ca++pump-ATPase demonstrated on the SEF plasma membrane may be involved in the regulation of intracytoplasmic Ca++ concentration.

Hepatic stellate cells express Ca2+ pump-ATPase and Ca2+-Mg2+-ATPase in plasma membrane of caveolae

Intracytoplasmic free calcium ions (Ca2+) are maintained at a very low concentration in mammalian tissue by the extrusion of Ca2+ across a steep extracellular Ca2+ gradient, mainly through the activity of plasma membrane Ca2+ pump-ATPase. The present study aimed to identify, by electron cytochemical and electron immunogold methods, the ultrastructural localizations of two types of plasma membrane Ca2+-ATPase; Ca2+-Mg2+-ATPase and Ca2+ pump-ATPase, in hepatic stellate cells. Liver tissues and isolated hepatic stellate cells (HSCs) were studied. The ultrastructural localization of Ca2+-Mg2+-ATPase activity was examined by the electron cytochemical method of Ando. The localization of Ca2+ pump-ATPase was identified by immunofluorescence. The ultrastructural localization of Ca2+ pump-ATPase was identified by the electron immunogold method. The cytochemical reaction products of Ca2+-Mg2+-ATPase activity were localized on the outer (cavity) side of the plasma membrane of caveolae. Immunofluorescence of Ca2+ pump-ATPase was seen as small dots along the cell edge in HSCs. Immunogold particles indicating the presence of Ca2+ pump-ATPase were identified on the inner (cytoplasmic) side of the plasma membrane of caveolae. We localized Ca2+ pump-ATPase on the inner side of the plasma membrane caveolae and Ca2+-Mg2+-ATPase on the outer leaflet of the caveolar plasma membrane in stellate cells, suggesting that Ca2+ pump-ATPase may play a key role in the Ca2+ reflux.

Acute renal failure in accidental hypothermia of cold water immersion

We report a 27-year-old Japanese man who developed acute renal failure associated with cold water immersion. The clinical course was consistent with that of acute renal failure attributable to acute tubular necrosis. A renal biopsy specimen showed patchy and focal loss of tubule cells, necrotic epithelium, interstitial edema, and arterial lumina obstructed by diffuse and severe intimal thickening. Endothelin increased more than five times in the early phase of the clinical course. Vasoconstriction and ischemia induced by cold exposure seem to lead to endothelin release. Endothelin may be related to the development of acute renal failure and intimal thickening.

Effect of postural change on urine volume and urinary sodium excretion in diabetic nephropathy

Fluid retention develops relatively early in the renal insufficiency of patients with diabetic nephropathy. The objective of this study was to clarify the effect of postural change on urine volume and urinary sodium excretion in diabetic nephropathy. Subjects consisted of 16 patients with non-insulin-dependent diabetes mellitus (five with diabetic nephrotic syndrome [DNS], five with nonnephrotic overt diabetic nephropathy [NNODN], and six without overt diabetic nephropathy [ODN]) and 11 patients with nondiabetic renal diseases (five with nondiabetic nephrotic syndrome [NDNS] and six without nephrotic syndrome). Patients were studied during 60 minutes of recumbency, followed by 60 minutes of standing. Mean blood pressure decreased in the standing posture only in patients with DNS and nondiabetic renal diseases. Urine volume decreased in the standing posture in the three groups of diabetic patients. Urine volume showed no changes in the standing posture in nondiabetic patients with and without nephrotic syndrome. The decreases in mean blood pressure and urine volume and the percentage decrease in creatinine clearance were significantly larger in patients with DNS than in those with NDNS and NNODN. The increase in free water clearance was significantly smaller in patients with DNS than in those with NDNS and NNODN. Urinary sodium excretion decreased in the standing posture in diabetic and nondiabetic patients, while no differences in the magnitude of changes were noted among patients with NDNS, NNODN, and DNS. It is concluded that the standing posture causes a greater decrease in urine volume due to orthostatic hypotension in patients with DNS compared with those with NDNS and NNODN, and that the presence of orthostatic hypotension in patients with DNS is likely responsible for the greater fluid retention of this group compared with other nephrotic patients with similar degrees of hypoalbuminemia.

A close association between brain lacuna infarction and renal surface irregularity

This study was undertaken to examine the association between brain lacunae examined by magnetic resonance imaging (MRI), and the severity of renal ischemia, evaluated by computed tomography (CT). We reviewed 114 cases, out of 1694 brain MRI studies and 2861 kidney CT studies undertaken between May 1994 and March 1996 in which both brain MRI and kidney CT were examined. Brain lacunae were defined as low intensity areas between 5 mm and 10 mm in diameter with the T1-weighted image. The severity of irregularity of the renal surface was classified as one of three grades: absent, mild, or severe. The prevalence of brain lacunae in cases with the renal surface irregularity classified as absent, mild, or severe was six of 45, 14 of 45, and 17 of 24, respectively. There was a highly significant relationship (P < .001) between the prevalence of brain lacunae and the severity of the renal surface irregularity. This relationship persisted, even when the subjects were restricted to include hypertensive patients > 60 years old. The irregularity of the renal surface is mainly caused by ischemia due to arteriosclerosis in the renal arteries. The results reported here suggest that brain lacuna infarcts are closely associated with renal ischemia, implicating a causative role of renal ischemia for brain lacunae.

Changes in plasma levels of nitric oxide derivative during low-density lipoprotein apheresis

The negative charges of dextran-sulfate (DS) used for low-density lipoprotein (LDL) apheresis activates the intrinsic coagulation pathway, in which plasma kallikrein acts on high-molecular-weight kininogen (HMWK) to produce large amounts of bradykinin. This study was undertaken to see whether bradykinin generated during DS LDL apheresis has some physiologic effects in vivo. The plasma levels of bradykinin and nitric oxide derivatives (NOx) were examined when either of 2 anticoagulants, heparin or nafamostat mesilate (NM), was used during DS LDL apheresis. Although anticoagulative action by NM depends on the inhibition of thrombin activity, this substance also inhibits the activity of plasma kallikrein. During apheresis using heparin, the marked increase in bradykinin levels (before apheresis, 18 +/- 3 (mean +/- SE, n = 5) pg/ml; after apheresis 470 +/- 140, p < 0.01) was associated with the increase in NOx (before apheresis 50 +/- 11 pg/ml; after apheresis 66 +/- 15). Interestingly, these changes in bradykinin and NOx levels were suppressed during apheresis using NM. The changes in plasma NOx levels were negatively correlated with those in blood pressures. These findings suggest that bradykinin generated during apheresis exerts some physiologic effects by means of activation of endothelium-derived relaxant factor (EDRF). Our results support the view that bradykinin produced during DS LDL apheresis has physiologic significance.

Changes in bradykinin and prostaglandins plasma levels during dextran-sulfate low-density-lipoprotein apheresis

The negative charges of dextran-sulfate (DS) used for low-density-lipoprotein (LDL) apheresis initiate the intrinsic coagulation pathway in which plasma kallikrein acts on the high-molecular-weight kininogen to produce large amounts of bradykinin. This study was undertaken to assess whether bradykinin generated during DS LDL apheresis has any physiologic effects in vivo. The plasma levels of bradykinin, prostaglandins and cyclic guanosine monophosphate (cGMP) were compared. when either of two anticoagulants, heparin or nafamostat mesilate (NM), was used during DS LDL apheresis. Although anticoagulative action by NM depends on the inhibition of thrombin activity this substance also inhibits the activity of plasma kallikrein. During apheresis using heparin, the plasma levels of prostaglandin E2 (PGE2) increased significantly (5.6 +/- 1.2 (mean +/- SE, n = 4) pg/ml before apheresis and 33.4 +/- 13.2 after apheresis, p < 0.05) in association with an increase in bradykinin levels (17.9 +/- 2.6 pg/ml before apheresis and 470 +/- 135 after apheresis, p < 0.01). Interestingly, these changes were suppressed during apheresis using NM. There were no appreciable changes in cGMP during DS LDL apheresis with either of the anticoagulants. This finding suggests that bradykinin generated during apheresis has some pathophysiological effects via activation of the prostaglandin system. Our results support the view that in patients taking angiotensin-converting-enzyme inhibitors, the anaphylactoid reaction occurring during apheresis may be caused by an excessive rise in the bradykinin levels.

[A case of ANCA-associated rapidly progressive glomerulonephritis with oral aphtha and erythema nodosum]

We reported a case of a 22-year old female with a microscopic form of polyarteritis nodosa (PN) who initially manifested Behçet's disease-like symptoms, such as fever, arthralgia, oral aphtha and erythema nodosum, and rapidly progressive glomerulonephritis (RPGN). On admission, her urinalysis showed active nephritic syndrome and her renal function rapidly deteriorated; serum creatinine levels elevated from 1.2 to 3.9 mg/dl within 2 weeks. Skin biopsy specimens from erythema showed panniculitis. Accordingly, she was treated with daily 30 mg of oral prednisolone and three-day intravenous pulse therapy of 1000 mg of methylprednisolone twice. After treatment, skin eruption and oral aphtha disappeared, and the serum creatinine level improved to 1.2 mg/dl. Percutaneous renal biopsy performed on the 28th day showed focal necrotizing glomerulonephritis and hyalinosis of small arteries. Immunofluorescence studies showed only trace stainings for IgG, IgA and beta lc. Electron microscopic findings revealed fusion of the foot process and swelling of endothelial cells, but no dense deposits. Anti-neutrophil cytoplasmic antibody (ANCA) was positive for IgG class with a 40-fold titer by indirect immunofluorescence test and showed a cytoplasmic pattern combined with high urinary IL-8 level (280.1 pg/ml). We diagnosed this case as a microscopic form of PN. ANCA titer and urinary IL-8 correlated positively with the disease activity, and were finally below 8-fold and 58.6 pg/ml, respectively after resolution of RPGN for 42 months. In this case, ANCA was useful not only for differential diagnosis of the patients with systemic vasculitis and crescentic glomerulonephritis, but also for evaluation of the disease activity.

Risk factors for infection and immunoglobulin replacement therapy in adult nephrotic syndrome

Infection has been recognized as an important cause of morbidity and mortality in children with nephrotic syndrome. However, the incidence and severity of infection and the mechanisms responsible for the increased susceptibility to infection are still unclear in adults. We studied 86 consecutive adult patients with nephrotic syndrome but no diabetic nephropathy. Risk factors for infection were evaluated by logistic regression analysis. Infections were found in 16 patients (19%), of whom six died of infection and two developed end-stage renal failure associated with infection. The relative risk for bacterial infection among patients with serum immunoglobulin G (IgG) levels below 600 mg/dL was 6.74 compared with that for patients with serum IgG levels over 600 mg/dL (95% confidence interval, 1.22 to 36.32; P = 0.029). In patients with serum creatinine levels over 2.0 mg/dL, the relative risk of bacterial infection was 5.31 compared with patients with serum creatinine levels below 2.0 mg/dL (95% confidence interval, 1.08 to 26.09; P = 0.040). Intravenous immunoglobulin (10 to 15 g) was administered prospectively every 4 weeks to 18 patients with serum IgG levels below 600 mg/dL until serum IgG levels increased to over 600 mg/dL. Administration of immunoglobulin resulted in a decreased rate of bacterial infections to a level equal to that in patients with endogenous levels over 600 mg/dL. These data indicate that hypogammaglobulinemia and renal insufficiency are independent risk factors for bacterial infection in adult patients with nephrotic syndrome. The effects of intravenous immunoglobulin suggest that maintenance of serum IgG levels over 600 mg/dL may reduce the risk of infection.

[Shortening of life expectancy in patients with membranous nephropathy--based on 20 years follow up study]

It is not certain whether the life expectancy of patients with membranous nephropathy is shorter than that of an age-matched healthy population. Forty-one patients (21 males, 20 females) aged between 16 and 70 years (average age: 33.3 years) were followed for 20 years. The patients were divided into two groups: group I (n = 18), consisting of patients in whom nephrotic syndrome persisted for more than two years or until death, and group II (n = 23), consisting of patients except for group I. The non-survival criteria are death or renal death. Twelve patients (29.3%) died during the study period. Eight patients belonged to group I and 4 to group II. The causes of death in group I patients were end-stage renal failure in 3 cases, ischemic heart disease in 1 case, subarachnoid hemorrhage in 1 case, malignancy in 2 cases, suicide in 1 case, and those in the group II patients were pneumonia, malignancy, cerebral softening, and diabetes mellitus, respectively. Eight patients who died in group I had a significantly longer difference between their actual life span (ALS) and life expectancy (LE) and a significantly smaller ratio of ALS to LE than the patients who died in group II (ALS-LE: -29.9 +/- 4.5 years in group I vs. -9.0 +/- 6.8 years in group II, p < 0.05, ALS x 100/LE: 22.5 +/- 8.0% in group I vs. 80.9 +/- 25.2% in group II, p < 0.05). In group I, the ratio of observed to expected death was 4.76 (95% confidence interval, 2.05 to 9.37) and significantly higher than that of the control population. In group II, however, the ratio was 1.09 (95% confidence interval, 0.30 to 2.80), and the difference from the control population was not statistically significant. These results suggest that longstanding nephrotic syndrome is associated with a shortened life expectancy in patients with membranous nephropathy.

[Risk factors for contrast nephropathy in diabetic patients undergoing cardioangiography]

Risk factors for contrast nephropathy were prospectively studied in 17 patients with non-insulin dependent diabetes mellitus undergoing cardioangiography. Contrast nephropathy, defined as a serum creatinine increase of greater than 25% at 3 day after angiography, occurred in 29.4% of diabetic patients. Patients who developed contrast nephropathy had significantly higher serum creatinine (Cr), fractional excretion of sodium (FENa), urinary albumin excretion rate (AER), and lower 24hr Ccr than patients who did not (Cr: 1.5 +/- 0.3 mg/dl vs. 0.8 +/- 0.1 mg/dl, FENa: 1.9 +/- 0.5% vs. 0.6 +/- 0.1%, AER: 522 +/- 335 micrograms/min vs. 27 +/- 13 micrograms/min, 24hr Ccr: 39.1 +/- 11.6 ml/min vs. 86.2 +/- 9.3 ml/min, P < 0.05). Contrast nephropathy developed in all of two patients with overt proteinuria (AER more than 200 micrograms/min), but none of eight patients with normoalbuminuria (AER below 15 micrograms/min). Three of seven patients with microalbuminuria developed contrast nephropathy, and two of them had advanced nephropathy. FENa obtained next day was significantly elevated over baseline in patients with contrast nephropathy (1.9 +/- 0.5% vs. 9.7 +/- 4.5%, P < 0.05), but unchanged in patients without contrast nephropathy. The rise in C beta 2-microglobulin/Ccr and enzymuria was noted in both group. Percentage decrease of Ccr on the next day was positively correlated with FENa before angiography (r = 0.645, p < 0.01). Of 24hr Ccr, AER, and FENa before angiography, FENa was revealed as a statistically significant discriminant factor for contrast nephropathy by stepwise discriminant analysis (p = 0.0008). These results suggest that contrast nephropathy develops predominantly in the stage not of incipient but of overt diabetic nephropathy indicated by a decline of glomerular filtration, overt proteinuria, and tubular dysfunction. Of them, tubular dysfunction may be the most important risk factor for contrast nephropathy.

[Steroid pulse therapy in rapidly progressive glomerulonephritis]

In an attempt to clarify the indication and efficacy of the methylprednisolone pulse therapy (1000 mg x 3 times) for rapidly progressive glomerulonephritis (RPGN), 3 patients with the disease were carefully followed and the clinical course during and after the treatment were precisely analysed. According to the declination rate of reciprocals of serum creatinine (1/Cr), one patient were divided into the acute type (-1.00 x 10(-2) dl/mg/day or less) and the others into the subacute type (more than -1.00 x 10(-2) dl/mg/day). In the patient of acute type, renal biopsy revealed cellular crescent formation in 93.8% of glomeruli observed. One course of the pulse therapy resulted in a decrease in Cr from 3.0 mg/dl to 1.3 mg/dl and transformation of cellular crescents to fibrocellular or fibrous crescents. In the other two patients of subacute type, crescents were observed in 72.7% and 72.0% of glomeruli observed, and 87.5% and 38.9% of them were composed of cellular crescents respectively. Initial courses of the pulse therapy resulted in decreases of Cr from 3.5 mg/dl to 2.4 mg/dl and from 3.0 mg/dl to 1.4 mg/dl respectively. Additional courses, given because of insufficient reduction of Cr in the former, induced a further lowering to 1.3 mg/dl, and because of re-elevation of Cr to 2.2 mg/dl and remaining of cellular crescents in 20% in the latter, induced a decrease of Cr to 1.5 mg/dl and disappearance of cellular crescents.(ABSTRACT TRUNCATED AT 250 WORDS)

Intraglomerular expression of MHC class II and Ki-67 antigens and serum gamma-interferon levels in IgA nephropathy

In order to clarify intraglomerular cellular activation and cytokine involvement in IgA nephropathy, the glomerular expression of MHC class II antigens (HLA-DR and DQ) and cellular proliferative nuclear antigen (Ki-67), and serum gamma-interferon (gamma-IFN) levels were evaluated in 49 patients with IgA nephropathy. HLA-DR was detected in all but 4 patients in whom glomerular sclerosis was present. HLA-DQ and Ki-67 were observed in 51 and 38% of the patients, respectively. Proteinuria, recent macroscopic hematuria, mesangial proliferation, and extracapillary and endocapillary lesions were more frequent and more severe in HLA-DQ-positive than in HLA-DQ-negative patients. In 10 patients with acute exacerbation, endocapillary lesions and HLA-DQ and Ki-67 expression were present in 70, 80 and 88%, respectively. Serum gamma-IFN levels were high in the patients (2.0 +/- 0.3 U/ml, n = 40), especially during acute exacerbation (3.4 +/- 1.1 U/ml, n = 9). Glomerular HLA-DO and Ki-67 expression correlated with serum gamma-IFN levels (r = 0.73, p less than 0.01 for HLA-DQ; r = 0.75, p less than 0.01 for Ki-67). Renal biopsy specimens taken before and after prednisolone and/or urokinase therapy were available from 4 patients. There was strong reactivity to HLA-DQ in the glomerular tufts of all 4 pretreatment samples. However, HLA-DQ reactivity disappeared after treatment in 3 samples, concomitant with normalization of serum gamma-IFN levels. We conclude that serum gamma-IFN levels are related to glomerular HLA-DQ and Ki-67 expression and acute exacerbation in patients with IgA nephropathy.(ABSTRACT TRUNCATED AT 250 WORDS)

[Aberrant expression of major histocompatibility complex class II. (HLA-DR/DQ) antigens and proliferative nuclear antigen. (Ki-67) in renal tubular epithelial cells]

In an attempt to clarify the participations of cellular immunity in the development of tubulo-interstitial lesions, aberrant expressions of major histocompatibility complex (MHC) class II antigens and Ki-67 nuclear antigen on the renal tubular epithelial cells were studied. Ki-67 antigen was known to appear in all phases of cell cycle except for Go. Nine normal kidney specimens (4 males and 5 females) and 117 kidney specimens obtained from patients with kidney diseases (54 males and 63 females) were examined with the indirect immunofluorescence technique using murine monoclonal antibodies against HLA-DR (lal), HLA-DQ (Leu10) and Ki-67 nuclear antigen. Patients included 100 with glomerular diseases, and 16 with tubulo-interstitial diseases consisting of 4 acute tubular necrosis (ATN), 7 acute tubulo-interstitial nephritis (AIN), one renal allograft rejection and 4 sarcoidosis. In normal kidney, HLA-DR was solely noted in only two specimens (22.2%) at the basal portion of proximal tubular epithelial cells. In tubulo-interstitial diseases 11 (68.8%) out of 16 patients showed diffuse and intense expressions of HLA-DR concomitant with HLA-DQ in 6 of 13 (42.9%), and 11 of 13 (84.6%) were positive for Ki-67 nuclear antigen. Especially, in AIN and allograft rejection, intense expression of HLA-DR, DQ and Ki-67 nuclear antigen were observed in 100%, 86%, 100%, respectively. In ATN 3(75%) were positive for HLA-DR and Ki-67, but not for HLA-DQ. In contrast, only 12(15.6%). 2(2.6%) and 2(4.8%) of primary glomerular disease were weakly positive for HLA-DR, DQ and Ki-67 nuclear antigen, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

[Double-blind comparative clinical evaluation of cefamandole and cefmetazole in the treatment of respiratory tract infections]

Cefamandole sodium (CMD), a new cephalosporin-derivative, was synthesized in the Laboratory of Eli-Lilly Co. Ltd. U.S.A. in 1972. CMD, which is several times more active than cefmetazole (CMZ, a cephamycin antibiotic) against Gram-positive cocci, is only as active as the latter antibiotic against Gram-negative bacilli. Against Haemophilus influenzae, CMD exhibits an antimicrobial activity which is as strong as that of ampicillin sodium. Our previous comparative tests on efficacy and safety of CMD versus cefazolin (CEZ) demonstrated that CMD was as effective and safe as CEZ in the treatment of respiratory tract infections. In the present clinical trial, the efficacy and safety of CMD are evaluated by a comparative double blind method using CMZ, a more recently synthesized cephamycin antibiotic, as a reference drug. For this purpose, a comparative double blind study was carried out in 50 institutions and clinics in Tohoku and Hokkaido districts in Japan. A total of 272 inpatients, who was aged over 16 years and was diagnosed as having pneumonia, lung abscess or acute infectious exacerbation of chronic obstructive pulmonary diseases, was included in this trial. They received 2 g of CMD or CMZ twice a day by intravenous drip infusions, as a rule, for 14 days. Of these patients, 264 (133 received CMD and 131 CMZ) were available for the evaluation of safety and usefulness. Two hundred and thirty-eight patients (122 received CMD and 116 CMZ) were adopted for the evaluation of efficacy. Prior to the treatment, there was no significant difference with respect to age, sex, severity of infection and underlying diseases between subjects in 2 treatment groups. An excellent or good clinical response was obtained in 82% of the patients treated with CMD, and in 81% of those treated with CMZ. Thus, there was no significant difference in cure rate between 2 treatment groups. However, an excellent clinical response was found in 12.3% of the patients treated with CMD, whereas only in 4.3% of those treated with CMZ. This difference in percentage of excellent clinical response between 2 treatment groups was statistically significant (P less than 0.05). Of the 87 patients with moderate to severe infection who were treated with CMD, 13 showed an excellent response. Only 4 of 90 patients treated with CMZ showed an excellent response. Statistically the difference in the rate of excellent response between these 2 groups was significant (P less than 0.05).(ABSTRACT TRUNCATED AT 400 WORDS)

[Clinical evaluation of cefoxitin against intractable bronchopulmonary infections. Patients not responding to other conventional antibiotics (author's transl)]

Cefoxitin was administered to a total of 17 patients with intractable bronchopulmonary infections who had failed to respond to other conventional antibiotics, and the following results were obtained. (1) The clinical response, except 1 patient classified as evaluation impossible, was excellent in 3 patients, good in 10 and fair in 3 with an efficacy rate of 81.3%. (2) An improvement rate of more than 70% was observed in the findings of body temperature, dyspnea, colour of sputum, WBC and CRP. (3) There was no subjective nor objective side effects attributable to cefoxitin. In view of the results stated above, we have concluded that cefoxitin is a useful antibiotic for the treatment of intractable bronchopulmonary infections.